Table 5.

Risk factors for change in type of work, decrease in work hours, long sick leave, and need for help at
work, by multivariate logistic regression analysis. All models were adjusted for age, sex, race, and education
level. Physically demanding work was based on patient reports that at least 20% of a typical work day was spent
lifting, bending, kneeling, or crawling.

Change in Type of Work Decrease in Work Hours

OR 95% CI p OR 95% CI p

Women 2.78 1.35–5.71 0.006 1.78 1.15–2.75 0.01

HAQ Disability Index — 3.06 1.95–4.81 < 0.0001
Pain score 3.60 2.22–5.81 < 0.0001 2.29 1.67–3.14 < 0.0001
Physically demanding work 2.39 1.13–5.01 0.03 —

Long Sick Leave Need for Help at Work

OR 95% CI p OR 95% CI p

Women — —
HAQ Disability Index 5.17 2.34–11.43 < 0.0001 5.40 2.69–10.81 < 0.0001
Pain score 2.12 1.17–3.84 0.02 2.06 1.26–3.36 0.004
Physically demanding work — 2.84 1.47–5.48 0.002

HAQ: Health Assessment Questionnaire.

DISCUSSION with an increased risk of a change in the type of work or the

In this cohort, permanent work disability was not common,
but temporary work disability or changes in the nature or
structure of work due to AS occurred in up to 30% of
patients. The prevalences of permanent work disability and
changes in type of work were similar to those reported in
previous studies1,3,5,7,8. Important risk factors for permanent
work disability were an older age at onset of AS, less formal
education, and a history of jobs requiring more physical
activity. Having a comorbid condition was an additional risk
factor for receipt of disability payments. Women were more
likely than men to receive disability payments for AS,
change their type of work, or report the need for help at
work. Patients with more severe or more active AS, as
reflected in functional disability or pain measures, were also
more likely to either change their type of work, decrease
work hours, have a long sick leave, or need help from
others. Having a job that involved more physical activity
was also a risk factor for change in the type of work and
need for help at work. A range of other factors, including
race, occupational category, health habits, recreational
activity, short term changes in symptoms, and freedom of
movement at work were not associated with work disability.
Similar to the results of studies of patients with other
rheumatic diseases11-16, heavy physical activity at work was
a risk factor for several different aspects of work disability
in our cohort. The likelihood of permanent work disability
and receipt of disability payments increased with the
average physical activity rating of jobs held by patients over
their lifetime. Results were similar using either ratings of
work activity assigned to specific jobs by the US
Department of Labor, or ratings by patients of their recalled
levels of work activity. Having a job that required prolonged
lifting, bending, kneeling, or crawling was also associated
need for help at work. Only 2 studies examined the nature of
work tasks as a possible risk factor for work disability in AS.
Lehtinen reported that patients employed in heavy manual
labor were more likely to become permanently work
disabled or to change jobs than patients whose jobs did not
involve heavy labor1. Guillemin and colleagues reported
that employment in jobs that required prolonged standing
was a risk factor for work disability, although having a phys-
ically demanding job was not6. Heavy work may worsen
musculoskeletal symptoms, or require flexibility or
endurance that patients with AS cannot always match.
Patients may retain employment if they are able to modify
the work tasks to ones they can accomplish, change their
type of work, or receive help intermittently, but permanent
work disability may result if these accommodations are not
possible.
Patients with less formal education were also more likely
to have permanent work disability or receive disability
payments8,9. These associations were present despite adjust-
ment for the physical demands of work, indicating that work
loss among less well educated patients was not solely attrib-
utable to their involvement in jobs requiring more physical
activity. Patients with less formal education or of lower
socioeconomic status may have fewer available employ-
ment options, or fewer options that can accommodate their
impairments. They may be less able or less apt to retrain and
learn new skills that would permit them to remain
employed. Similar factors may contribute to the increased
risk of work disability with an older age at onset of AS.
Patients who develop AS after becoming established in their
careers may be more likely to retire if no longer able to do
their work than to learn a new set of work skills. Vocational
rehabilitation did not help patients avoid work disability,

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320 The Journal of Rheumatology 2001; 28:2

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possibly because it was used too late in the disablement
process. Previous studies have not reported sex differences
in work disability among patients with AS, although Gran
and colleagues found the prevalence of work disability to be
somewhat higher among women4,9. Women in our study
were no more likely than men to have permanent work
disability, but they were almost twice as likely to receive
disability payments, a marker of temporary work disability.
Many of these payments to women occurred within the first
year of AS, suggesting that AS may have a more pronounced
effect on women. This finding is also supported by other
results from this cohort that indicate women are more likely
than men to have severe fatigue, pain, and functional limita-
tions23. Even after adjusting for sex differences in pain and
functional disability, women were more likely to change
their type of work or decrease their work hours. That women
were more likely to make these adaptations, yet no more
likely to have permanent work disability, indicates that these
strategies were largely effective in allowing them to remain
employed.
Not unexpectedly, patients were more likely to experi-
ence changes in the nature or structure of their work during
periods of more pain and higher levels of functional
disability. These factors may also influence the likelihood of
the longterm outcomes of permanent work disability or
receipt of disability payments, but we did not have prospec-
tive data on pain, stiffness, or functional disability to assess
this association. We also did not examine associations with
physical limitations, such as reduced lumbar flexibility or
peripheral arthritis, because the onset of these limitations
could not be accurately ascribed in our retrospective study.
The risk factors examined in the retrospective study were
those that did not vary over time or ones that could be reli-
ably ascertained by patient recall. Our study participants
were predominantly white, well educated, and from one
geographic area, which limits the representativeness of our
cohort. Because the risk of work disability varies with the
level of formal education, the prevalence of work disability
would likely be higher in groups of patients with more
diverse educational or socioeconomic backgrounds.
Nonetheless, we were able to demonstrate differences in the
risks of work disability among patients with different levels
of formal education.
Given the association between physical activity at work
and work disability, patients with AS should be counseled to
avoid jobs that require heavy physical activity. For patients
who have not yet begun full-time work, education or
training for less physically demanding jobs offers better
prospects for lifelong employment. To be effective, efforts
at retraining those with physically demanding jobs for
lighter work may need to begin long before physical impair-
ment develops.
ACKNOWLEDGMENT
We thank Cheryl Kallmann for expert technical assistance.
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Ward and Kuzis: Work disability in AS
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REFERENCES
1. Lehtinen K. Working ability of 76 patients with ankylosing
spondylitis. Scand J Rheumatol 1981;10:263-5.
2. Carette S, Graham D, Little H, Rubenstein J, Rosen P. The natural
disease course of ankylosing spondylitis. Arthritis Rheum
1983;26:186-90.
3. McGuigan LE, Hart HH, Gow PJ, Kidd BL, Grigor RR, Moore TE.
Employment in ankylosing spondylitis. Ann Rheum Dis
1984;43:604-6.
4. Gran JT, Østensen M, Husby G. A clinical comparison between
males and females with ankylosing spondylitis. J Rheumatol
1985;12:126-9.
5. Wordsworth BP, Mowat AG. A review of 100 patients with
ankylosing spondylitis with particular reference to socio-economic
effects. Br J Rheumatol 1986;25:175-80.
6. Guillemin F, Briançon A, Pourel J, Gaucher A. Long-term disability
and prolonged sick leave as outcome measurements in ankylosing
spondylitis. Possible predictive factors. Arthritis Rheum
1990;33:1001-6.
7. Ringsdal VS, Helin P. Ankylosing spondylitis — education,
employment and invalidity. Dan Med Bull 1991;38:282-4.
8. Roussou E, Kennedy LG, Garrett S, Calin A. Socioeconomic status
in ankylosing spondylitis: relationship between occupation and
disease activity. J Rheumatol 1997;24:908-11.
9. Gran JT, Skomsvoll JF. The outcome of ankylosing spondylitis: a
study of 100 patients. Br J Rheumatol 1997;36:766-71.
10. Ward MM. Quality of life in patients with ankylosing spondylitis.
Rheum Dis Clin North Am 1998;24:815-27.
11. Yelin EH, Henke CJ, Epstein WV. Work disability among persons
with musculoskeletal conditions. Arthritis Rheum 1986;29:1322-33.
12. Yelin E, Henke C, Epstein W. The work dynamics of the person
with rheumatoid arthritis. Arthritis Rheum 1987;30:507-12.
13. Reisine ST, Grady KE, Goodenow C, Fifield J. Work disability
among women with rheumatoid arthritis. The relative importance of
disease, social, work, and family factors. Arthritis Rheum
1989;32:538-43.
14. Reisine S, McQuillan J, Fifield J. Predictors of work disability in
rheumatoid arthritis patients. A five-year followup. Arthritis Rheum
1995;38:1630-7.
15. Partridge AJ, Karlson EW, Daltroy LH, et al. Risk factors for early
work disability in systemic lupus erythematosus. Results from a
multicenter study. Arthritis Rheum 1997;40:2199-206.
16. Wolfe F, Hawley DJ. The longterm outcomes of rheumatoid
arthritis: work disability: a prospective 18 year study of 823
patients. J Rheumatol 1998;25:2108-17.
17. Ward MM, Kuzis S. Validity and sensitivity to change of
spondylitis-specific measures of functional disability. J Rheumatol
1999;26:121-7.
18. Goei The HS, Steven MM, van der Linden SM, Cats A. Evaluation
of diagnostic criteria for ankylosing spondylitis: a comparison of
the Rome, New York, and modified New York criteria in patients
with a positive clinical history screening test for ankylosing
spondylitis. Br J Rheumatol 1985;24:242-9.
19. US Department of Labor. Selected characteristics of occupations
defined in the Dictionary of Occupational Titles, 1981. Supplement
to the US Department of Labor Dictionary of occupational titles.
Washington, DC: US Department of Labor; 1977.
20. Fries JF, Spitz P, Kraines RG, Holman HR. Measurement of patient
outcomes in arthritis. Arthritis Rheum 1980;23:137-45.
21. Cox DR. Regression models and life tables. J Roy Stat Soc
1972;34:187-202.
22. Liang K-Y, Zeger SL. Longitudinal data analysis using generalized
linear models. Biometrika 1986;73:13-22.
23. Ward MM. Health-related quality of life in ankylosing spondylitis:
a survey of 175 patients. Arthritis Care Res 1999;12:247-55.
321